Too Much Stupid Stuff

by Kim Bellard, November 16, 2018

Melinda Ashton, M.D., has a great article in NEJMGetting Rid of Stupid Stuff. It describes a program her health system (Hawaii Pacific Health) undertook to do exactly that, with some promising results.

The impetus of their program was to address the issue of burnout, specifically around documentation burdens. Their EHR had been in place for 10 years, and they reasoned that some tasks might no longer be necessary or appropriate. So, starting October 2017, they asked all employees to nominate anything in their EHR that was “poorly designed, unnecessary, or just plain stupid.”

Dr. Ashton and her team reminded employees that: “Stupid is in the eye of the beholder. Everything that we might now call stupid was thought to be a good idea at some point.” Fair enough. They expected nominations to be in three categories:

  • unintended documentation that could easily be eliminated;
  • documentation that was needed but that could be collected more efficiently;
  • documentation that needed better training to accomplish.

They ended up getting nominations in all three categories, and have already implemented a number of changes, as well as eliminating 10 of the most frequent 12 physicians alerts. The program has now been extended beyond just documentation and beyond just the EHR because, as Dr. Ashton writes: “It appears that there is stupid stuff all around us.”

It would be easy but short-sighted to take healthcare’s collective frustration out on EHRs. But let’s not kid ourselves: EHRs are not the stupidest thing we have in healthcare. EHRs may, in fact, be the smartest stupid thing healthcare has done, because at least there are significant upsides to having EHRs, even if we’re not achieving them yet. There are plenty of things we do in healthcare that are just plain stupid.

Admit it: if you work in healthcare, you see stupid stuff every day. Some are things imposed on you from external sources, and some are things required by your own organization. As Dr. Ashton cautioned, some may have been a good idea at some point. Some may never have been a good idea. Some are things that just keep getting done simply because of habit/ tradition/rules. Some are stupid things that someone, somewhere, still thinks is a good idea but, when push comes to shoving patient care, aren’t. They’re still stupid, and should be stopped.

The program at Hawaii Pacific Health as aimed primarily at reducing daily frustrations for its employees, but we need to go much further. These kinds of programs need to attack daily frustrations for all stakeholders, and especially for patients.

If you are a healthcare leader, start a program like this. If you work in a healthcare organization, advocate for one until your leadership puts one in. If you are a patient or family member of one, don’t wait for a formal program from the healthcare organizations you interact with; speak up about the stupid stuff you see and have to deal with, and make sure your thoughts get to those organizations’ leadership.

It’s stupid to accept stupid stuff, especially with something as valuable as our health at stake.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


Friday Five: Top 5 healthcare business news items from the MCOL Weekend edition

Every business day, MCOL posts feature stories making news on the business of health care. Here are five we think are particularly important for this week:

As states race to expand Medicaid, AHIP study reaffirms the program's value

The effectiveness of Medicaid, as compared to private insurance, has long been a matter of debate, but in recent years conservative critics have not-so-quietly suggested that the program provides no improvement to beneficiaries' health whatsoever.

Fierce Healthcare

Thursday, November 15, 2018

More leeway for states to expand inpatient mental health

The Trump administration Tuesday allowed states to provide more inpatient treatment for people with serious mental illness by tapping Medicaid, a potentially far-reaching move to address issues from homelessness to violence.

AP News

Wednesday, November 14, 2018

With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment

When mental illness hijacks Margaret Rodgers’ mind, she acts out. Rodgers, 35, lives with depression and bipolar disorder. When left unchecked, the conditions drive the Alabama woman to excessive spending, crying and mania.

Kaiser Health News

Tuesday, November 13, 2018

Cigna app targets reduction of risks for expecting moms

Health insurer Cigna is launching a mobile app to connect members to its Healthy Pregnancies and Healthy Babies prenatal program.

Health Data Management

Tuesday, November 13, 2018

Veritas Capital, Elliott to buy Athenahealth for $5.7 billion

Private equity firm Veritas Capital and hedge fund Elliott Management are buying Athenahealth Inc (ATHN.O) for about $5.7 billion, the U.S. healthcare software maker said on Monday.


Tuesday, November 13, 2018

These and more weekly news items on the business of healthcare are featured in the MCOL Weekend edition, along with the MCOL Tidbits, and more, for MCOL Premium level members.


He/She Said | Doctor Said

by Clive Riddle, November 9, 2018

The AAFP (American Academy of Family Physicians) has highlighted a new Harris Poll survey - commissioned by the Samueli Integrative Health Programs  - that shows "there are considerable gaps between what primary care physicians (PCPs) discuss with their patients and what patients would like to discuss with their physician." In particular, the concern raised from the survey seems to be that this communication gap is an impediment to SDOH (social determinants of health) goals.

AAFP reports that "although 74 percent of adults said they typically had discussions about physical health with their physician -- and more than 50 percent had discussions about test results, medications and exercise -- discussions about other key factors, including issues related to social determinants of health, were reported by less than half of respondents."

AAFP elaborates that "Fifty-two percent of adults said they and their physician didn't discuss much more than medical needs, such as physical symptoms, test results, medications and surgical history. Conversely, 53 percent of adults wished their physician would talk to them about nonmedical therapies such as nutrition, acupuncture, massage therapy and meditation, and 45 percent of adults said they wished they and their physician talked more about why they want to be healthy."

Here's some more details:

  • 42% had discussions about the patient's diet
  • 40% had discussions on sleep
  • 36% had discussions about the patient's mental health
  • 20% discussed why it is personally important to the patient to be healthy
  • 13% discussed the patient's personal environment
  • 11% discussed what brings the patient joy and happiness
  • 10% had discussions about the patient's spiritual health

Wayne Jonas, M.D., the executive director of Samueli Integrative Health Programs, comments on the communication gap, stating "Part of the disconnect stems from how doctors are trained. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral and environmental factors that contribute to most chronic diseases. Unfortunately, patients will often defer to their doctor about what is discussed during their appointment, so if it's not brought up by their doctor, they may not be likely to mention it."

Another study published this month in JMIR mHealth and uHealth might offer hope for improvement in patient-physician communication in the form of mHealth.  The study: Simulated Clinical Encounters Using Patient-Operated mHealth: Experimental Study to Investigate Patient-Provider Communication was designed to examine “how personal mobile technology, under patient control, can be used to improve patient-provider communication about the patient’s health care during their first visit to a provider.”

The study found that “Overall, encounter and task times averaged slightly faster in almost every instance for the treatment group than that in the control group. Common ground clearly was better in the treatment group, indicating that the idea of designing for the secondary UX to improve provider outcomes has merit.”

But the age of technology advancing mHealth also has brought the avalanche of available medical information to patients. Combined with increased availability of direct-to-consumer medical products and services that empower patients to have greater autonomy in their healthcare, resulting challenges emerge in patient-physician communication.

The challenges are addressed in a JAMA article published last month: The New Age of Patient Autonomy - Implications for the Patient-Physician Relationship. The authors state that “expanded access to information and to a variety of health-related products and services will bring new opportunities for patients to direct their own health care. It will also bring new challenges for physicians who must manage the downstream consequences of tests and screens they did not order. Most important, the new age of patient autonomy will necessitate that physicians reconceptualize their role in the patient-physician relationship.

The authors conclude that in this new age of autonomy, physicians may need to act in the following three capacities: 

  1. "Physicians will serve as consultants or advisors to patients who will increasingly direct their own care."
  2. "Physicians will continue to perform diagnostic and therapeutic procedures that patients are not able to carry out."
  3. "Although physicians will still be the gatekeepers of many medical resources, the function of gatekeeping will change. The availability of DTC products and services has pushed physicians gatekeeping back a level."



Searching for the Key to the New Front Door to Healthcare

By Clive Riddle, November 2, 2018

Oliver Wyman’s just released 2018 consumer healthcare survey report: Waiting for Consumers, appropriately includes a picture of a door on its cover, as the headline on the second page of narrative reads “The New Front Door, Try It, You’ll Like It.” The report concludes that “those who have tried alternative forms of healthcare delivery are happy with them” and “despite that finding, there hasn’t been much change in the number of consumers – about 10 percent – who have actually used the new front door, though the number who say they are willing to try is rising sharply.”

A very meaningful insight, no doubt – but I got stuck at the new front door. What rock have I been hiding under (a large one evidently) that I haven’t been fully immersed in discussion of healthcare’s new front door? I like doors. I like new things. I would very much would have liked to have been in on hearing all about healthcare’s new front door back when discussing the door was still new, and not evidently, when everyone who is anyone has been talking about the new front door for some time.

So I set out to find out all about healthcare’s new front door, and what awaits behind it. The Oliver Wyman report enlightened me that the door is constructed of retail clinics and telehealth, but not enough people are walking through it yet, although many are thinking about taking the plunge. They state “what has changed since our last survey is consumer willingness to try new kinds of health services. For example as shown in Exhibit 3, almost 40 percent of consumers in our 2018 survey said they would be comfortable receiving treatment for minor medical issues through a retail clinic, and 35 percent of consumers would receive that care through telehealth – in both casesan increase of 12 percentage points since 2015 when we asked consumers this same question.”

So clearly Oliver Wyman has been working with this door for several years. I wanted to find out more. Two seconds later, my first google search yielded their March 2016 report entitled The New Front Door to Healthcare is Here, which tells us: “over the past few years, there has been much discussion about the need for a ‘new front door to healthcare.’ In general, this refers to moving certain types of care out of the emergency room and doctor’s office and delivering it through more convenient means, such as a retail clinic, urgent care center, or telehealth.” 

So now we know about the old front door being replaced. In particular, the emergency room has borne that label for considerable time. That old front door can be expensive, and take a heck of a lot of time to get through.

The 2016 Oliver Wyman report goes on to say that “The ‘new front door’ is not about replicating today’s healthcare system in a more convenient setting. Instead, the new front door is about bolstering today’s healthcare system with a variety of consumer-friendly access points. The new front door is multi-dimensional (urgent care centers, retail health clinics, telehealth consultations, mobile apps). It is very clear that individually, none of these can deliver the full promise of the new front door. In fact, if offered as individual point solutions, consumer experience, health outcomes, and cost could suffer. An integrated new front door strategy, however, holds tremendous promise for consumers, payers, providers, and retailers alike.” Oliver Wyman had knocked on the door in previous years as well, such as this July 2015 piece: How Healthcare's New Front Door is Opening Up Opportunities.

But after leaving their thoughtful reports, I encountered a number of doors, like a contestant on the old Let’s Make a Deal Show:

  1. CEOs of CVS Health, Aetna say merger will offer new front door to healthcare
  2. Could Alexa Become the New Front Door to Healthcare?
  3. By Opening a Front Door to Care, Telehealth Will Finally (Finally) Take Off

Then as I pondered which door to choose, I learned the front door might be from those sci-fi or paranormal films, where it shifts all around while you attempt to enter it, as I was told How Healthcare Leaders Adapt to the Evolving Front Door to Care.

Which finally led me to read that Patients might need map to find 'front door' to health care, as the story asks “what and where is the real "new front door to health care in America?"

I will continue my quest searching for the key.



Two Reports on Cost Driven Deferred Medical Care

By Clive Riddle

Two reports were published this week on deferred medical care driven by cost considerations, based on survey findings. Earnin’s report: Waiting to Feel Better: Survey Reveals Cost Delays Timely Care is based on two surveys – a commissioned online Harris Poll among over 2,000 U.S. adults and an Earnin poll of their users, “many of which live paycheck to paycheck.” AccessOne’s report: AccessOne Patient Finance Survey- Analysis on how healthcare costs impact is based on a survey conducted by ORC International of 693 people with at least $35,000 in annual household income, weighted by age, sex, geographic region, race and education.

Earnin tells that 54% of Americans “have delayed medical care for themselves in the past 12 months because they could not afford it, “ with the top three most delayed types of care being dental/orthodontic work (55%), eye care (43%), and annual exams (30%.) Earnin reports that “23 percen) have put off getting medical care for more than one year because they could not afford it. Among those whose household is living paycheck to paycheck or not making enough to get by, the rate of this extremely delayed care averages 36 percent. Nearly half of Americans (49 percent) say their health tends to take a back seat to other financial obligations.”


AccessOne reports that “Twenty-seven percent of households with children are likely to delay care because they can’t afford to pay for it.” Focusing on the dollar amounts involved and financing issues, they tell us that
  • 21% of families who had trouble paying their medical bill reported that their accounts had been sent to collections.
  • More than half of respondents were concerned about their ability to pay a medical bill of less than $1,000; with 35 percent being concerned about paying a bill that totals less than $500 – 20 times less than the average healthcare balance of a person in the U.S.
  • Only 21 percent of respondents said their healthcare providers have spoken to them about available patient financing options in the past two years.
  • Fifty-five percent of those surveyed said they prefer to discuss healthcare costs and financing options before care of service is delivered.
  • Fifty-four percent of those surveyed said they would use a no-interest financing option for a balance of $1,000 or less, and 57 percent said availability of a no-interest finance option is important or very important in evaluating a provider.
So if the AccessOne report implications bear out that improving financing options up front will reduce deferred medical care, the question is, will our younger generations that have had to assume much greater overall burden of college debt, also assume a growing burden of medical debt?